= Explanation Codes =

These codes are descriptive codes that identify what was done to the claim line and the denial explanation.

codes in '''bold''' are considered most relevant for LA DPS&C 
|| Code  || Description || Explanation ||
||  04   || Expense not covered by plan || Return to CCIH if Code # 04 is seen by itself. MCOB Code, sometimes left on in error, denied for another reason. ||
||  06   || Inmate not eligible || Sent back on Eligibility spreadsheet by DPS&C ||
||  13   || PPO Benefits applied || Populates on all paid claims ||
||  24   || Duplicate charge || May be one line or entire claim ||
|| '''27'''   || '''Claim adjustment''' || Additional payment on a previously paid claim. Possibly when the wrong contract rate was used for first payment. ||
||  32   || Paid by previous carrier ||  ||
||  36   || Duplicate of a corrected claim || May be one line or entire claim ||
|| '''40'''   || '''Additional payment''' || Used with Code 27 (e.g. Bill Type 137, or appeal received) ||
||  42   || Inmate responsible for charges || Paroled inmate, CCIH does not send out EOB. Vendor must bill inmate. ||
||  44   || Not covered, member responsible || Paroled inmate or charges for personal items ||
||  45   || Re-file with physicians name || Physician's name is missing ||
||  46   || Prior to effective date of group ||  ||
||  47   || Submit itemized statement || Additional data required for inpatient bill ||
||  48   || Inclusive with per Diem rate || Facilities with per diem rate; charge amount may be more than allowed ||
||  50   || Submit entire medical record || Additional data required ||
||  51   || Amount previously billed || Duplicate- a second claim requested differently for same DOS ||
||  57   || Not a state inmate ||  ||
||  65   || Late charges are not covered ||  ||
||  67   || Other coverage primary ||  ||
||  82   || Corrected EOB || EOB will not see; returned from DPS&C ||
|| '''95'''   || '''Claim denial upheld''' || Vendor appeal- claim did not change ||
||  96   || Inmate on medical furlough ||  ||
||  107   || Corrected claim received ||  ||
||  108   || Does not change amount paid || Used in conjunction with Denial Code # 95 ||
||  114   || Cannot bill assistant surgeon charges || surgery is not qualified for an assistant surgeon per Medicare ||
||  121   || Inmate paroled || On Eligibility information returned from DPS&C ||
||  123   || Invalid CPT code- resubmit || Use of an older or not eligible code; must refile claim ||
||  130   || Diagnosis not valid for sex ||  ||
||  131   || Newborn care is not covered ||  ||
||  137   || Included in case rate || Same as a bundled charge for services- Replacing Code # 165 ||
||  139   || Included with DRG rate ||  ||
||  146   || No allowance for modifier 26 || Charge is not allowed to be read usually for the 2nd time; Medicare guidelines ||
||  150   || Convenience items not covered || Inpatient bill charges such as telephone or tv ||
||  151   || After hours charges not covered || Used in conjunction with Medicare guidelines ||
||  153   || Invalid age for CPT code || Used if billed incorrectly a CPT invalid for the age of patient ||
||  154   || Invalid sex for CPT code ||  ||
||  155   || Invalid place of service ||  ||
||  156   || Invalid modifier code ||  ||
||  157   || Invalid diagnosis code ||  ||
||  158   || Invalid age for diagnosis ||  ||
||  159   || Unacceptable primary diagnosis ||  ||
||  160   || Incidental procedure || Part of bundled procedures; physician bill ||
||  161   || Charge included in another code || Same as Code # 193 & 194 ||
||  162   || CPT not valid for service date || Billing error; provider billed originally with an invalid code ||
||  163   || Included in global time period || Same as Code # 204 & 137 ||
||  164   || Possible catastrophe ||  ||
||  165   || Included in global allowance || Multi-lined claim and amount all-inclusive; cannot allow additional monies; rebill if no monies paid originally ||
||  166   || Not medically necessary ||  ||
||  167   || Elective procedure not covered ||  ||
||  168	 || Cosmetic procedure non covered ||  ||	 
||  169	 || Secondary Diagnosis required ||  ||
||  170	 || Non specific Primary Diagnosis ||  ||	 
|| '''171''' || '''Invoice required for payment''' || Invoice required per contract for specific service (ex.blood, implant) ||
||  172	 || Claim paid by DPS&C || Duplicate; another claim received by CCIH that DPS&C has already paid ||
||  173	 || Resubmit Claim with DRG code || Missing DRG code ||
||  174	 || Not eligible ||  ||	 
||  177	 || Page 1 of 2 missing, resubmit ||  ||	 
||  178	 || Page 2 of 2 missing, resubmit ||  ||	 
||  179	 || Submit additional documentation || e.g. Admin Dates ||
||  184	 || Resubmit claim by fiscal Year || Claim crossing two FYs ||
||  186	 || Claim returned to DPS&C || Regents, Alvarado Physician- any claims returned DPS&C ||
||  187	 || Multiple pages missing, re-bill ||  ||	 
||  188	 || Resubmit with CPT code || Facility bills missing CPT codes with Revenue codes ||
||  190	 || No diagnosis code submitted ||  ||
||  191	 || Please resubmit with diagnosis ||  || 
||  192	 || Bill lacks required modifier/CPT code || Missing billing code, modifier or CPT for this line of service ||
||  193 & 194 || Code is a component of another; not allowable	|| Used together, with 3M pricing ||
||  195 & 196 || Code not recognized by OPPS; alternate code available; re-bill    || Used together, with 3M pricing. ||
||  197	 || Resubmit Corrected Billing ||  ||	 
||  202	 || CPT/Procedure code not allowable || 3M pricing, not allowed by Medicare. (e.g. 99053) ||
||  203	 || Invalid bill type; resubmit || Using an invalid Bill Type ||
||  204	 || Inclusive with Base Rate	|| Same as Code # 163 & 165 ||
||  205	 || Multiple surgery reduction || Claim line reduced due to Multiple Surgeries- Medicare Guidelines ||
||  206	 || Invalid use of modifier || ||
||  207	 || Incidental charges reported, re-bill || Medicare no pay for incidental charges w/o complete hospital billing on UB04 ||
||  208	 || Provide pick up address and zip || Ambulance billing ||
||  209	 || Submit anesthesia code || ||
||  210	 || Units exceed medical necessity || 3M MUE Edit ||
||  211	 || Not eligible per DPS&C contract || ||
||  212	 || No RVP for this procedure || ||
||  213	 || Inappropriate use of modifier || ||
||  214	 || Covered inpatient service only || 3M OCE EDIT ||
||  215	 || CPT does not match description || ||
||  218	 || Invalid tax ID || ||
||  219	 || Inappropriate specification of || 3M OCE Edit/017 ||
||  220	 || Bilateral procedure OCE|| 219 & 220 used as one denial ||
||  221	 || Claim lacks required device code || ||
||  222	 || EDI-No tax ID submitted on claim || ||
||  223	 || Re-bill on HCFA 1500 claim form || ||
||  224	 || Service not billable to FI/MAC || Fiscan Intermediary / Medicare Administration ||
||  225	 || Provide service facility address || ||
||  226	 || Requires HCPCS on same line || 3M Edit 0048OCE 0048 ||
||  227  || No payee data record || ||
||  228	 || Resubmit with height & weight || Dialysis claims only use # 228 & 229 together ||
||  229	 || of patient || ||
||  230	 || Dental service not covered || by CCIH ||
||  231	 || Covered w/ condition code only || UB charges ||
||  232	 || Non allowed service for OPPS || 3M Edit ||
||  233	 || Future service not payable || ||
||  234	 || Registry charge returned to DPS&C || ||
||  235	 || DME/Orthotics covered by DPS&C || ||
||  236	 || Surgeon cannot bill as assistant || Surgeon billing as the Assistant's charges ||
||  237	 || Condition code required on bill || 3M 00420CE ||
||  238	 || DPS&C refund received || ||
||  239	 || Resubmit with only one base rate || Ambulance billing ||
||  240	 || No charges were submitted || ||
||  241	 || Billable by hospital only || Contract based ||
||  242	 || EDI- No inmate Name submitted || ||	 
||  243	 || EDI -No CDCR number submitted || ||
||  244	 || Claim lacks required device code || 3M edit 00710CE ||
||  245	 || Code not recognized by Medicare || Outpatient claims 3M edit 0028 ||
||  246	 || Code only billable to DMERC(RTP) || 3M edit 061 OCE ||
||  247	 || Verify Date of Service submitted || ||
||  248	 || Previously paid as assistant || 248 & 249 used together when assistant charge is billed by Surgeon ||
||  249	 || surgeon || ||
||  250	 || Units > 1 is inappropriate || 3M edit 0074 OCE ||
||  251	 || Invalid revenue code || ||
||  253	 || Incorrect billing of blood || ||
||  254	 || or blood products || 3M edit 0074 OCE ||
||  255	 || Trauma response w/ critical care || ||
||  256	 || Requires REV code with CPT code || 3M edit ||
||  257	 || Re-bill using procedure(s) code(s) || ||
||  258	 || as contracted || 257 & 258 used as one denial ||
||  259	 || Please submit Medicare fiscal || ||
||  260	 || intermediary letter || 259 & 260 used as one denial ||
||  261	 || Statutory exclusion list and not || ||
||  262	 || covered by Medicare outpatient || 3M edit ||
||  263	 || Co-surgeon not permitted || ||
||  264	 || ADJ-01 not completed/signed || ||
||  265  || Incorrectly billed address || ||
||  266	 || in box 33, please resubmit  || 265 & 266 used as one denial ||
||  267	 || Admin Days denied by DPS&C || ||
||  268	 || Mutually exclusive to another || ||
||  269	 || CPT code billed || 268 & 269 used as one denial ||
||  270	 || Submit supporting documentation || ||
||  271	 || Per DPS&C UM inmate ineligible || ||
||  272	 || Per DH at DPS&C || ||
||  273	 || Additional paid to contracted || ||
||  274	 || rate || Use 273 & 274 as one denial ||
||  275  || NDC code required for payment || ||
||  276	 || No inmate name submitted  || ||
||  277	 || Inmate not seen on || ||
||  278	 || Date of Service || Use 277 & 278 as one denial ||
||  279	 || DRG submitted does not match CMS || ||
||  280	 || group DRG code; submit || ||
||  281	 || corrected DRG code || Use 279, 280, & 281 as one denial ||
||  282	 || Claims with handwritten || ||
||  283	 || information are not accepted || Use 282 & 283 as one denial ||
||  284	 || Administrative fee included in || ||
||  285	 || reimbursement || Use 284 & 285 as one denial ||
||  286	 || Re-bill Health Net, date of || ||
||  287	 || service on new claim || Use 286 & 287 as one denial ||
||  288	 || Services packaged into PAC rate || ||
||  289	 || Medicare non-covered item / service || ||
||  290	 || Claim lacks required device code || ||
||  291	 || radio labeled product; resubmit || Use 290 & 291 as one denial ||
||  292	 || Clinical diagnostic lab services || ||
||  293	 || Claim service crosses contract with || ||
||  294	 || PPO, please split and re-bill || Use 292 & 293 as one denial ||
||  295	 || Incidental services packaged || ||
||  296	 || into APC rate || Use 295 & 296 as one denial ||
||  297	 || Adjustment / refund error || ||
||  298	 || NDC submitted is invalid || ||
||  299	 || Not approved per ADJ-01 form || ||
||  300  || Add on code not reimbursable || ||
||  301  || because valid primary CPT absent || Use 300 & 301 as one denial ||
||  302	 || Invalid age/gender for CPT code || ||
|| '''303''' || '''Invalid age/gender for HCPCS''' || ||
||  304	 || E&M service previously paid for || ||
||  305	 || DOS, only one allowed per day || Use 304 & 305 as one denial ||
||  306	 || Patient seen within last 3 yrs || ||
||  307	 || by physician, submit established || ||
||  308	 || CPT code || Use 306, 307, & 308 as one denial ||
||  309	 || Patient seen within last 3 yrs || ||
||  310	 || by physician, an established || ||
||  311	 || code was reimbursed || Use 309, 310, & 311 as one denial ||
||  312	 || Included in global surgical || ||
||  313	 || package for major surgery and is || ||
||  314	 || not separately reimbursable || Use 312, 313, & 314 as one denial ||
||  315	 || Included in global surgical || ||
||  316	 || package for minor surgery and is || ||
||  317	 || not separately reimbursable || Use 315, 316, & 317 as one denial ||
||  318	 || This procedure is incidental to || ||
||  319	 || another service on this Date of || ||
||  320	 || Service and is not reimbursable || Use 318, 319, & 320 as one denial ||
||  321	 || This service is not reimbursable || ||
||  322	 || based on the place of service || Use 321 & 322 as one denial ||
||  323	 || This service is not covered || ||
||  324	 || An Assistant Surgeon, Co-Surgeon || ||
||  325	 || or Team Surgeon for this CPT is || ||
||  326	 || unnecessary and not reimbursed || Use 324, 325, & 326 as one denial ||
||  327	 || An Assistant Surgeon, Co-Surgeon || ||
||  328	 || or Team Surgeon for this CPT || ||
||  329	 || requires additional documentation || Use 327, 328, & 329 as one denial ||
||  330	 || Procedure submitted with more || ||
||  331	 || than one multiple surgeon || ||
||  332	 || modifier || Use 330, 331, & 332 as one denial ||
||  333	 || Invalid modifier for procedure || ||
||  334	 || Duplicate charge || ||
||  335	 || Exceeds the appropriate || ||
||  336	 || number of units per day || Use 335 & 336 as one denial ||
||  337	 || Exceeds the appropriate || ||
||  338	 || units for defined time frame || Use 337 & 338 as one denial ||
||  339	 || Component included with other || ||
||  340	 || CPT billed for Date of Service || Use 339 & 340 as one denial ||
||  341	 || Mutually exclusive to another || ||
||  342	 || procedure billed || Use 341 & 342 as one denial ||
||  343	 || Unlisted procedure requires || ||
||  344	 || additional documentation || Use 343 & 344 as one denial ||
||  345	 || Not medically necessary based on || ||
||  346	 || National Coverage Determination || Use 345 & 346 as one denial ||
||  347	 || Included in global || ||
||  348	 || obstetric package || Use 347 & 348 as one denial ||
||  349	 || Procedure is part of a lab panel || ||
||  350	 || and is not reimbursable || Use 349 & 350 as one denial ||
||  351	 || CPT is add on code and cannot be || ||
||  352	 || billed as a standalone code || Use 351 & 352 as one denial ||
||  353	 || Included in global surgical || ||
||  354	 || package for another CPT billed || Use 353 & 354 as one denial ||
||  355	 || Status B code payment included || ||
||  356	 || in payment for other services on || ||
||  357	 || same Date of Service || Use 355, 356, & 357 as one denial ||
||  358	 || Invalid diagnosis code || ||
||  359	 || Status T code included in other || ||
||  360	 || CPT payment for same DOS || Use 359 & 360 as one denial ||
||  361	 || Another E&M service billed for || ||
||  362	 || same provider and same DOS ||  ||
||  363	 || this CPT will not be reimbursed || Use 361, 362, & 363 as one denial ||
||  364	 || Global period applies, same || ||
||  365	 || CPT billed with previous DOS || Use 364 & 365 as one denial ||
||  366	 || Refund received and applied || ||
||  367	 || CPT code not valid for date of || ||
||  368	 || service billed || Use 367 & 368 as one denial ||
||  369	 || Unlisted procedure or service || ||
||  370	 || is not reimbursable || Use 369 & 370 as one denial ||
||  371	 || CPT submitted with multiple || ||
||  372	 || units exceeding the CMS ||  ||
||  373	 || Medically Unlikely Edit || Use 371, 372, & 373 as one denial ||
||  374	 || CPT/HCPCS is not valid for Date || ||
||  375	 || of Service submitted on claim || Use 374 & 375 as one denial ||
||  376	 || Invalid diagnosis code submitted || ||
||  377	 || Submit supporting medical || ||
||  378	 || documentation || Use 377 & 378 as one denial ||
||  379	 || Invalid principle DX code || ||
||  380	 || Service not separately payable || ||
||  381	 || Code2 of a Code1/Code2 || ||
||  382	 || paid; needs modifier || Use 381 & 382 as one denial  ||
||  383	 || Service units out of range || ||
||  384	 || Invalid HCPCS code || ||
||  385	 || Modifier required for payment || ||
||  386	 || Diagnosis code requires ALS || ||
||  387	 || HCPCS code. || use 386 & 387 as one denial ||
||  388	 || Not payable due to invalid base ||  ||
||  389	 || rate HCPCS code || use 388 & 389 as one denial ||
||  391	 || Revenue code requires HCPCS code || ||
||  392	 || Packaged / Incidental services || ||
||  393	 || Invalid bill type || ||
||  394	 || Invalid Place of Service || ||
||  395	 || Excluded from negotiated rate || ||
||  396	 || Provider compensation for this || ||
||  397	 || service is zero per Coventry || ||
||  398	 || Provider agreement || Use 396, 397, & 398 as one denial ||
||  399	 || Multiple medical visits, same || ||
||  400	 || revenue code, same date without || ||
||  401	 || condition code G0 || Use 399, 400, & 401 as one denial ||
||  402	 || No additional payment due, ||  ||
||  403	 || included with additional pricing || Use 402 & 403 as one denial ||
||  404	 || Claim lacks required device code || ||
||  405	 || Claim lacks required || ||
||  406	 || radio-labeled product || Use 405 & 406 as one denial ||
||  407	 || Invalid revenue code || ||
||  408	 || Invalid principle procedure || ||
||  409	 || Procedure/Sex conflict || ||
||  410	 || Procedure may only be performed || ||
||  411	 || in an inpatient setting || Use 410 & 411 as one denial ||
||  412	 || Place of Service not valid || ||
||  413	 || for procedure billed || Use 412 & 413 as one denial ||
||  414	 || Invalid procedure to modifier || ||
||  415	 || Lab test is component of a lab || ||
||  416	 || panel and require being || ||
||  417	 || billed using the panel code || Use 415, 416, & 417 as one denial ||
||  418	 || HSS ASC invalid Bill Type or || ||
||  419	 || Place of Service || Use 418 & 419 as one denial ||
||  420	 || Provider is not contracted for || ||
||  421	 || services submitted with this || ||
||  422	 || Bill Type/POS || Use 420, 421, & 422 as one denial ||
||  423	 || Medical visit with procedure || ||
||  424	 || without "25" || Use 423 & 424 as one denial ||
||  426	 || CMS rates not available || Health Net denial ||
||  427	 || Original bill required to price || ||
||  428	 || late charges || Use 427 & 428 as one denial ||
||  429	 || Inpatient service not paid || ||
||  430	 || under OPS || Use 429 & 430 as one denial ||
||  431	 || Packaged service/item; no || ||
||  432	 || separate payment || Use 431 & 432 as one denial ||
||  433	 || Service not covered by Medicare || ||
||  434	 || for free standing ASC || Use 433 & 434 as one denial ||
||  435	 || Component of comprehensive || ||
||  436	 || procedure not allowed || Use 435 & 436 as one denial ||
||  437	 || Service not billable to the || ||
||  438	 || fiscal intermediary || Use 437 & 438 as one denial ||
||  442	 || Invalid ICD procedure codes used || ||
||  443	 || Additional charges added || ||
||  444	 || Charges billed as non-covered || ||
||  447	 || No allowance for Asst. Surgeon || ||
||  448	 || NPI number does not match || ||
||  449	 || Physician in box 31 || ||
||  450	 || Therapy service requires modifier || ||
||  451	 || Invalid principle diagnosis || ||
||  452	 || Present on Admission || ||
||  453	 || POA codes are missing || Use 452 & 453 as one denial ||
||  454	 || Not medically necessary based on || ||
||  455	 || local coverage determination || Bloodhound denial; use 454 & 455 as one denial ||
||  456	 || NDC# submitted has been || ||
||  457	 || deactivated for this DOS || Use 456 & 457 as one denial ||
||  458	 || Status N code is non-covered || Bloodhound denial ||
||  463	 || Remit address does not match || ||
||  464	 || BIS account information on file || Use 463 & 464 as one denial ||
||  466	 || Zip code point of pick up || ||
||  467	 || is outside of supplier's contract || Use 466 & 467 as one denial ||
||  468	 || Invalid ADA code; resubmit || ||
||  469	 || Please verify charges submitted || ||
||  470	 || Incidental procedure not || ||
||  471	 || separately reimbursed || OCE Edit 047-Use 470 & 471 as one denial ||
||  472	 || Resubmit claim with correct || ||
||  473	 || NPI number || Use 472 & 473 as one denial ||
||  475	 || Discharge status is invalid || Use with code 197 ||
||  481	 || Invalid or missing CMG code || ||
||  484	 || G0379 only allowed with G0378 || OCE Edit 0058 ||
||  487	 || Service provided same day as || ||
||  488	 || an inpatient procedure || OCE Edit 049-Use 487 & 488 as one denial ||
||  493	 || Vendor should re-bill through || ||
||  494  || the hospital/surgery ctr/phys || Use 493 & 494 as one denial ||
||  500  || Packaged surgical procedures || ||
||  501  || include operation and || ||
||  502  || uncomplicated post-op care || Use 500, 501, & 502 as one denial ||
||  503  || Non-covered - inmate is a donor || ||
||  506  || RUG values missing || ||
|| '''507''' || '''DPS&C UM Audit required''' || ||
||  511  || Invalid DRG code || ||
||  513  || Line 1 does not match the || ||
||  514  || date of service billed in the || ||
||  515  || statement period submitted || Use 513, 514, & 515 as one denial ||
||  516  || Line service date is invalid || ||
||  517  || in box 32 for Place of Service || Use 516 & 517 as one denial ||
||  518  || Incorrect Bill Type || ||
||  519  || Admission Source Code, box 15 || ||
||  520  || missing or invalid || Use 518, 519, & 520 as one denial ||

codes in '''bold''' are considered most relevant for DPS&C